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General NPI Number Information
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NPI Number | 1295528727
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Entity Type | Individual
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Provider Name | MR. RE'QUAVAS JACQUI WRAY
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Gender | Male
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Dates
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Enumeration Date | 05/27/2025
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Last Update Date | 10/01/2025
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Provider Practice Location Address
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Address Line | 809 N LAFAYETTE ST STE A
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City | SHELBY
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State | NC
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Zip | 28150-3886
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Country | US
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Telephone | 704-284-0554
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Fax |
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Provider Business Mailing Address
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Address Line | 1635 S DEKALB ST APT 1011
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City | SHELBY
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State | NC
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Zip | 28152-7685
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Country | US
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Telephone | 704-466-9257
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | A22107
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License Number State | NC
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